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Lower Limb Replants

Lower Limb Replants. Dr Lip Teh. History. William Balfour (1814) - fingertip reattachment Thomas Hunter(1815) – thumb reattachment William Halstead and Alexis Carrel (1880s) - canine replantation experiments limbs

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Lower Limb Replants

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  1. Lower Limb Replants Dr Lip Teh

  2. History • William Balfour (1814) - fingertip reattachment • Thomas Hunter(1815) – thumb reattachment • William Halstead and Alexis Carrel (1880s) - canine replantation experiments limbs • Nobel Prize in 1912(Carrell) for his work on vascular anastomoses and renal transplantation. • Ronald Malt(1962) first successful replantation of an entire limb • 12-year-old boy severed arm. • Komatsu/Tamai (1968) – first microscopic digit replantation

  3. Lower limb amputations • Most commonly due to • High speed MVA • Train accidents • Occupational accidents

  4. Lower limb replants • Surgical options: • Amputation • Fillet /composite flaps (Jupiter PRS 1982) • Flap banking (Godina PRS 1986) • Replantation • Limb banking and secondary replantation (Hidalgo 1987)

  5. Lower limb replants • decision not to replant is much more compelling in lower limb • function of the lower extremity can be replaced by a prosthesis • the injury is more severe/multitrauma • the unpredictable recovery of repaired nerves • severe general complications or local complications such as necrosis, infections, nonunions • the need for secondary lengthening, or other reconstructive procedures • the economic cost to the patient and community is less.

  6. Lower limb replants • Indications • Young age • Bilateral amputations • Clean amputations • MESS • Energy, Shock, Ischaemia, Age • Short ischaemic time

  7. Lower limb replants • Goals • Functional • Sensate • Pain free • Stable • Aesthetically pleasing

  8. Lower limb replants • Bone shortening is not a contraindication • Crossover replantation • bilateral total or subtotal amputations, when anatomic replantation is not possible.

  9. Amputate or Replant • Data from limb salvage in lower limb injuries • J Trauma. 2002 Apr;52(4):641-9. • Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma.MacKenzie EJ, Bosse MJ, Kellam JF, et al • 527 patients with Gustilo type IIIB and IIIC tibial fractures, dysvascular limbs resulting from trauma, type IIIB ankle fractures, or severe open midfoot or hindfoot injuries. • CONCLUSION: Soft tissue injury severity has the greatest impact on decision making regarding limb salvage versus amputation.

  10. Amputate or Replant • J Trauma. 1997 Sep;43(3):480-5. • The functional outcome of lower-extremity fractures with vascular injury.Lin CH, Wei FC, Levin LS, Su JI, Yeh WL • 36 revasularisations for IIIC Fractures • overall secondary amputation rate 25% and the salvage rate 75% • 80% required secondary coverage procedures that included 12 free flap transfers • Every patient needed subsequent reconstructive surgery to achieve an acceptable functional result. In this series, • MESS was able to predict the secondary amputation rate and the functional result. • salvaged limbs with MESS < or = 9 exhibited a significant difference in achieving adequate function compared with limbs with MESS > 9. • onclusions are (1) more severely injured limbs have poor functional results, (2) every patient needs subsequent reconstructive surgery, and (3) the MESS may be helpful in decision-making.

  11. Amputate or Replant • Surgery. 1990 Oct;108(4):660-4 • Combined orthopedic and vascular injury in the lower extremities: indications for amputation.Odland MD, Gisbert VL, Gustilo RB, Ney AL, Blake DP, Bubrick MP. • 25 patients with vascular repairs; • The risk factors associated with amputation • shock on admission (10 of 19 patients [p less than 0.02]) • a crushed extremity (10 of 18 patients [p less than 0.01]). • The overall amputation rate 35.2%.

  12. Amputate or Replant • J Reconstr Microsurg. 2004 Nov;20(8):621-9. • Can indications for lower limb replantation and revascularization be expanded with simultaneous free-flap transfer for limb salvage?Akoz T, Yildirim S, Akan M, Gideroglu K, Avci G, Cakir B. • replanted or revascularized five lower limbs all had free tissue transfers • 1 latissimus dorsi muscle, 2 TRAM, and 2 anterolateral thigh flap. • 1 total failure – necrosis/infection • Indications for lower limb salvage may be enhanced and successful results may be obtained in one stage, with low complication rates and shorter hospital stays.

  13. Outcomes • Microsurgery. 1991;12(3):221-31 • Major limb replantation in children.Daigle JP, Kleinert JM. • 7 lower extremity replant • 87% of patients had a sensory recovery of more than S2+

  14. Outcomes • J Reconstr Microsurg. 1995 Mar;11(2):89-92. • A 17-year follow-up of replantation of a completely amputated leg in a child: case report.Masuda K, Usui M, Ishii S. • 4 year old lower leg replant • maintained good cosmesis and function • foot size on the affected side was 1.5 cm smaller • leg length was 1.2 cm shorter than on the normal side • half-standard strength of the evertors and of the plantar flexors • replantation in a growing child apparently has adverse influences on skeletal growth and muscle strength around the ankle joint.

  15. Outcomes • Ann Plast Surg. 1982 Apr;8(4):305-9 Lower extremity replantation-two and a half-year follow-up.Mamakos MS. • 11 year old above knee level • regained protective sensation to her foot. • fully ambulatory and uses a brace to stabilize her ankle • growth of the severed extremity ( 10 cm discrepancy to 5.5 cm).

  16. Outcomes • J Bone Joint Surg Am. 1990 Oct;72(9):1370-3. • Replantation of the distal part of the leg.Usui M, Kimura T, Yamazaki J. • five legs replants. • >2 year followup (average: six years). • Difficulties in squat and run because of joint contractures, muscle weakness, or deformities of the foot. • None had significant pain or any intolerance to cold, and all were satisfied with the results.

  17. Outcomes • J Bone Joint Surg Br. 2003 May;85(4):554-8. • Orthotopic and heterotopic lower leg reimplantation. Evaluation of seven patients. • Daigeler A, Fansa H, Schneider W. • five patients (orthotopic), two (heterotopic) • assessed cutaneous sensation, mobility, pain, cosmetic result. • Functional outcome, patient satisfaction - good, • Mobility, stability, and psychological state - satisfactory. • Patients with heterotopic reimplantations preferred the replanted leg to a prosthesis. • Asensate foot not a contraindication • Improves the patient's quality of life.

  18. Conclusion • Lower limb replant • Should be tried in • Children • Bilateral lower limb amputations • Compared to amputation, expect • prolonged hospital stay • delays mobilisation • secondary procedures. • Amputation with severe soft tissue injuries or other systemic injuries

  19. A world’s first? • Herald Sun 29 Mar 05: Prof Wayne Morrison, director of the Bernard O'Brien Institute of Microsurgery and head of plastic and hand surgery at Melbourne's St Vincent's Hospital, said he believed the operation was a world first. "We have had some cases of both legs, or a foot and a leg taken off, but we haven't had three limbs," Prof Morrison said. "To have three all combined, I think it must be certainly a first in Australia and I would think a first in the world." • Injury. 1997 Jan;28(1):73-6 • Replantation of four severed limbs in one patient.Pei GX, Kunde L, Chuwen C, Dengshong Z, Fuyi W, Songto W, Minsheng W, Lie G, Qing L, Lui CK, Zhang LL.

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